CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F583
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F584
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F644
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F656
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F690
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F695
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F761
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F812
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F838
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F880
F926Have policies on smoking.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-09Record 455962-20260108-F926
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 455962-20241009-F689
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-22Record 455962-20241009-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 455962-20241009-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-01Record 455962-20241009-F880
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F550
F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F582
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F584
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F609
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F641
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F644
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F657
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F695
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F699
F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F727
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F761
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F842
F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F849
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F925
F926Have policies on smoking.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-11Record 455962-20230912-F926
F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.Scope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2023-10-11Record 455962-20230912-F851